4 (Settings for Psychiatric Care)

Question 1

There is one bed on a locked psychiatric unit. Which of the following patients is appropriate for involuntary admission?

a. ) Jill, aged 23 years, a college student who has developed symptoms of anxiety and is missing classes and work
b. ) Michael, aged 30 years, an accountant who has developed symptoms of depression
c. ) Mia, aged 26 years, a kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road
d. ) Rose, aged 76 years, a retired librarian who is experiencing memory loss and some confusion at times

Answer 1

c.) Mia, aged 26 years, a kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road

Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient).

The other options can all be managed at this point in the community setting and don’t meet criteria (risk of harm to self and/or others) for admission.

Question 2

Which of the following structural safety precautions is most important to prevent the most common type of inpatient suicides?

a. ) Break-away closet bars to prevent hanging
b. ) Bedroom and dining areas with locked windows to prevent jumping
c. ) Double-locked doors to prevent escaping from the unit
d. ) Platform beds to prevent crush injuries

Answer 2

a.) Break-away closet bars to prevent hanging

Hangings are the most common method of inpatient suicide. The other options are important safety measures but don’t directly address the suicide method of hanging.

Question 3

Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)?

a. ) Ramon, who is suicidal with a plan
b. ) Marty, a substance abuser who is being discharged from an inpatient alcohol rehabilitation unit
c. ) Ellen, who stopped taking her antipsychotic medication and is decompensated and not caring for herself
d. ) Jeff, who has mild depression symptoms and is starting outpatient therapy

Answer 3

b.) Marty, a substance abuser who is being discharged from an inpatient alcohol rehabilitation unit

PHP is for patients who may need a “step-down” environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day.

This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP.

Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself.

A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.

Question 4

George W. Bush’s New Freedom Commission on Mental Health’s report emphasized that mental illness is not a hopeless life sentence but a condition from which people can recover. Recovery, which is still the number 1 goal, could be described as:

a. ) the ability to work, live, and participate in the community.
b. ) never having to visit a mental health provider again.
c. ) a short-term journey that leaves people better able to cope with symptoms.
d. ) a long-term journey over the individual’s life span.

Answer 4

a.) the ability to work, live, and participate in the community.

Recovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. Recovery is usually not a short-term journey but rather a long-term journey. While recovery may be a long-term journey over months or even years, it would not cover an entire life span.

Question 5

One primary goal and benefit of Assertive Community Treatment (ACT) is:

a. ) forming closer relationships with the patient’s family.
b. ) more flexible work schedule for staff.
c. ) more reimbursement to staff for services provided.
d. ) preventing rehospitalization.

Answer 5

d.) preventing rehospitalization.

A primary goal of ACT is working intensely with the patient in the community to prevent rehospitalization. The other options are not goals of ACT.

Question 6

The primary advantage of using a case manager is to

a. ) increase collaborative practice.
b. ) enhance resource management.
c. ) increase client satisfaction with care.
d. ) promote evidence-based psychiatric nursing.

Answer 6

b.) enhance resource management.

Case management coordinates and monitors the effectiveness of services appropriate for the client. In the community setting, for example, close monitoring permits rapid assessment of the need for crisis intervention to avoid costly readmission.

Question 7

Most clients who are diagnosed with chronic mental illness are not likely to have their psychiatric mental health experiences covered by

a. ) private insurance.
b. ) Medicare.
c. ) Medicaid.
d. ) Social Security.

Answer 7

a.) private insurance.

Because most health insurance is employer based, few chronically ill clients have private insurance.

Question 8

Which statement regarding clients’ rights after being voluntarily admitted to a behavioral health unit is true?

a. ) All rights remain intact.
b. ) Only rights that do not involve decision making remain intact.
c. ) The right to refuse treatment is no longer guaranteed.
d. ) All rights are temporarily suspended.

Answer 8

a.) All rights remain intact.

The hospitalized client is not a convicted criminal. All civil rights remain intact. Patients’ rights are clearly posted in all inpatient units.

Question 9

It is not always guaranteed that all clients who are voluntarily admitted to a behavioral health unit will have the right to

a. ) refuse treatment.
b. ) send and receive mail.
c. ) seek legal counsel.
d. ) access all personal possessions.

Answer 9

d.) access all personal possessions.

A client has the right to keep personal belongings unless they are dangerous. Items such as sharp objects, glass containers, and medication are usually removed from the client’s possession and kept in a locked area to be used by the client under supervision or returned at discharge.

Question 10

For the psychiatric client, the greatest negative aspect of the multidisciplinary treatment team approach to care is that it

a. ) is an expensive treatment model.
b. ) can increase anxiety in the newly admitted client.
c. ) requires the client to answer the same questions repeatedly.
d. ) puts demands on the client’s time and energy.

Answer 10

b.) can increase anxiety in the newly admitted client.

Newly admitted clients can find the interaction with numerous team members stressful or even threatening.

Question 11

An ongoing, crucial responsibility of nurses working on an inpatient psychiatric unit is

a. ) fostering research.
b. ) maintaining a therapeutic milieu.
c. ) sympathetic listening.
d. ) providing constructive negative feedback.

Answer 11

b.) maintaining a therapeutic milieu.

Nursing is the discipline primarily responsible for maintenance of a therapeutic milieu, an environment that serves as a real-life training ground for learning about self and practicing communication and coping skills in preparation for a return to the community outside the hospital.

Question 12

Which is a characteristic of a therapeutic inpatient milieu?

a. ) It provides for the client’s safety and comfort.
b. ) Voluntarily admitted clients are generally allowed additional privileges.
c. ) Rules and behavioral limits are flexibly enforced.
d. ) Staff provide frequent and ongoing negative feedback to clients.

Answer 12

a.) It provides for the client’s safety and comfort.

Because the acuity level on inpatient units is high, nurses are responsible for ensuring that the environment is safe and that elopement and self-harm opportunities are minimized. The other choices are undesirable characteristics of a therapeutic milieu.

Question 13

Which would NOT be considered a crisis on a psychiatric unit?

a. ) Mr. R reports chest pain after eating a spicy lunch.
b. ) Ms. T cannot speak and is holding her hands up to her neck.
c. ) Mr. S demonstrates anger that escalates to physical assault.
d. ) Mr. U reports hearing voices telling him to hit others.

Answer 13

d.) Mr. U reports hearing voices telling him to hit others.

Crises on a psychiatric unit can be either medical in nature or behavioral.

Medical crises include shock, cardiopulmonary arrest, hemorrhage, and status epilepticus, whereas behavioral crises include actual or potential violence against self, others, or the environment.

Option D is not considered a crisis, but rather a potential crisis that was averted.

Question 14

Which assessment information is uniquely important to the mental health client receiving outpatient care?

a. ) Mental status examination results
b. ) The client’s strengths and deficits
c. ) Housing adequacy and stability
d. ) The presenting problem and referring party

Answer 14

c.) Housing adequacy and stability

For hospitalized clients, the treatment team does not have to worry about whether the client has a clean, safe place to stay and adequate food to eat. For the client receiving care in the community, these are legitimate planning concerns.

Question 15

The major difference between the psychiatric nursing assessment performed for a client who is hospitalized and for a client who will be treated in the community is

a. ) for the latter, the general assessment must be expanded.
b. ) for the latter, the nursing focus is primarily on the mental status examination.
c. ) for the former, the general assessment must be reimbursement based.
d. ) for the former, the nursing focus is limited to the client’s willingness to accept treatment.

Answer 15

a.) for the latter, the general assessment must be expanded.

General assessment of clients in the community is expanded to include community living challenges and resources, the client’s ability to cope with the demands of living in the community, and the client’s willingness to accept community support.

Question 16

Which need is the highest priority for a seriously and persistently ill client living in the community?

a. ) Access to medication
b. ) Socialization and diversion
c. ) Independent decision making
d. ) Engaging in meaningful work

Answer 16

a.) Access to medication

After basic life necessities have been met, maintenance of the medication regimen is critical to preventing relapse and recurrence of the client’s illness. If the client does not have access to medication, he or she will be unable to be compliant.

Question 17

Although mental illness still carries a stigma, acceptance has improved over the past 40 years, partly due to

a. ) better control of symptoms through drug therapy.
b. ) public screenings that are well advertized in the community.
c. ) community psychiatric nursing programs that provide in-home care.
d. ) acknowledgment of personal mental health issues by well-known people.

Answer 17

d.) acknowledgment of personal mental health issues by well-known people.

Public discussion of mental illness by famous political, entertainment, and sports figures has proven helpful in minimizing the stigma attached to problems such as depression, anxiety, and eating disorders.

Question 18

Which criterion must be met to refer a client to a partial hospitalization program?

a. ) The client is hospitalized at night in an inpatient setting.
b. ) The client must be able to provide his or her own transportation daily.
c. ) The client is able to return home each day.
d. ) The client is able to care for his or her own physical and psychological needs.

Answer 18

c.) The client is able to return home each day.

Returning home each day is a criterion because doing so allows the person to test out new skills and gradually re-enter the family and society

Question 19

Which situation demonstrates the nurse functioning in the role of advocate?

a. ) Providing one-to-one supervision for a client on suicide precautions
b. ) Co-leading a medication education group for clients and families
c. ) Attending an inservice education program to obtain recertification in cardiopulmonary resuscitation
d. ) Negotiating with the client’s HMO for extension of a 3-day hospitalization to 5 days

Answer 19

d.) Negotiating with the client’s HMO for extension of a 3-day hospitalization to 5 days

In the inpatient setting, case managers on the hospital team communicate daily or weekly with the client’s insurer and provide the treatment team guidance regarding the availability of resources.

In the community, multiple levels of intervention are available within case management service, ranging from daily assistance with medications to ongoing resolution of housing and financial issues.

Question 20

A client was admitted to the behavioral health unit for evaluation and diagnosis after being found wandering the streets. His personal hygiene is poor, and his responses to questions are bizarre and inappropriate. The client’s constitutional rights are violated when the nurse states:

a. ) “We will help you make decisions that will keep you safe.”
b. ) “I am going to help you shower, so you will not smell so bad.”
c. ) “Your pocket knife and nail clippers will be kept in the nurses’ station.”
d. ) “You will be having a number of tests to help us learn about your condition.”

Answer 20

b.) “I am going to help you shower, so you will not smell so bad.”

Every client has the right to be treated with dignity. This statement is demeaning.

Question 21

Which symptomatology has priority for admission to an inpatient behavioral health unit?

a. ) Severe anxiety and feeling as though one is suffocating
b. ) Profound grieving over the recent death of one’s identical twin
c. ) Hearing voices that proclaim one to be “the exalted ruler of the universe”
d. ) History of seizures and an elevated lithium level

Answer 21

d.) History of seizures and an elevated lithium level

This modification requires careful titration and observation that would be difficult to provide on an outpatient basis. (Lithium toxicity can proceed to death.)

Question 22

A novice nurse is assigned to manage the milieu when there is a behavioral crisis with a client in the dining room. The nurse shows a lack of understanding of crisis management when

a. ) requiring that all clients go in their rooms.
b. ) moving clients from the dining room to the day room/solarium.
c. ) encouraging the clients to express their reactions to the incident.
d. ) reassuring clients that staff will handle the agitated client.

Answer 22

a.) requiring that all clients go in their rooms.

Other clients are usually taken to a safe area away from the scene of the crisis.

The nurse should allow clients to express their fears, which often include fear of bodily harm from the acting-out client, fear that they, too, could lose control, and fear for the other client’s safety.

The nurse should provide realistic reassurance for expressed concerns.

Question 23

The nurse who provides therapeutic milieu management supports the clients best by

a. ) allowing them to act out their fears and frustrations.
b. ) providing a safe place for them to practice coping skills.
c. ) meeting their physical as well as emotional needs.
d. ) encouraging them to talk about their problems with others.

Answer 23

b.) providing a safe place for them to practice coping skills.

A therapeutic milieu can serve as a real-life training ground for learning about the self and practicing communication and coping skills in preparation for a return to the community.